Quick Assist Loan Application For Active Duty Sailors And Marines
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1Local Unit Code:
________________
Quick Assist Loan Application for Active Duty Sailors and Marines
Active Duty ID and most recent LES are required to apply for this interest-free loan.
Date:
All elements of the application process must be completed prior to receiving a QAL.
Last Name:
First:
Middle:
Suffix:
SSN:
-
-
Branch of Service:
Military Status:
Rate/Rank: Pay Grade:
DOD ID#:
Navy
Marine Corps
Active
Reserve
>30
EAOS/ETS:
Date of Birth:
Military Unit:
: Local Home Address:
Permanent Home of Record:
UIC/RUC
Address:
Work Phone:
Cell Phone:
Home Phone:
Work Email:
Personal Email:
Marital Status:
#Dependents:
Preferred Contact Method: Please check
preferred email and phone above.
Single
Spouse is:
(Date:
)
Married
Divorced
(Date:
)
Civilian
Spouse Name:
Legally Separated
(Date:
)
Active Military
Reserve
Spouse Birth Date:
Spouse SSN:
Retired
Loan Information - to be completed by Active Duty service member
Amount Requesting: $
(minimum $100 to maximum $500)
Repay Months: 3
4
5
6
7
8
9
10
*Allotment must be a minimum of $11.00 per month.
The intended purpose of this loan is for:
BLE (housing, food, utilities, clothing)
Dental Expenses
Family Emergencies
Medical Expenses
Transportation
Are you pending any type of early discharge/release?
Yes
No
Are you pending, or have you had any disciplinary action in the last 6 months
which resulted in a fine and/or reduction in rank?
Yes
No
Are you under Chapter 7 or Chapter 13 bankruptcy protection?
Yes
No
IMPORTANT: Please advise if you are currently in an “overdraft” status with your bank. The bank may use these funds to recoup their money.
Signature Block
The above information is true and accurate to the best of my knowledge. I am aware of all my financial obligations and I
am able to repay this loan. I understand that monies loaned from the Navy-Marine Corps Relief Society are donated by
my fellow Sailors and Marines.
Signature:
Date:
NMCRS 222 (February 2013)
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